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These might include: Pregnancy test : Essential first step for any woman of reproductive age with menstrual changes Blood tests : To assess hormone levels (FSH, LH, oestradiol, prolactin, thyroid function) and full blood count if bleeding is heavy STI screening : Particularly for unexplained intermenstrual or postcoital bleeding Pelvic ultrasound : If structural causes need to be excluded Review of medication : To ensure no drug interactions or other contributing factors Keep a menstrual diary noting cycle length, flow heaviness, and any associated symptoms

Cell 115 , 851862 (2003)